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Letters to the Editor |
Szent-Lazár County Hospital, 3100 Salgótarján, Hungary
Received 3 March 2009; accepted 20 March 2009.
* Corresponding author. Address: Kórház Street 5, Csitár, 2673, Hungary. Tel.: +36 35 371 110; fax: +36 35 570 011. (Email: eccehomo{at}syscon.hu).
Key Words: Malignant respiratory fistulas • Palliation • Effectiveness
I would like to congratulate to Balázs et al. [1] for their article on the treatment of malignant esophagorespiratory fistulas.
According to the report, 71.2% of their 264 patients underwent endoscopic tube implantation rate resulting in an overall oral intake rate of 54.5% of their whole patient population. One wonders what was the reason of insuitability of the method in the remaining 72 cases?
Aerodigestive fistulas combined with a mild or secondary malignant stricture of the esophagus, accompanied by serious esophageal axis divergencies and/or associated mediastinal cavity are the major challenges. In my opinion these conditions mark the veritable limits of the reported method of endobronchial intubation. I doubt if a procedure with exclusion of the above detailed conditions might aspire to the title of most effective or even the optimal type of palliation.
Using my individually tailored cuffed funnel tube inserted by minimally invasive pull-through insertion technique [2] all of the 47 attempts of intubation were successful in cases of different kinds of malignant fistulas with (or without) associated esophageal stricture (1983–2002, Korányi Institute, Thoracic Surgical Clinic, Budapest, Hungary). This type of intubation has a lot of advantages in secondary malignant strictures and fistula of the esophagus.
In instances of fistula without esophageal stricture or complicated by a mediastinal cavity (unfavorable condition for conventional tube placement) a double cuffed tube (flange + body) was developed and applied. The overall hospital mortality was 6.4%; the rate of nonfatal complications was 1.8%.
In spite of a successfully positioned conventional prostheses liquids or even solid food can enter the fistula (25% of Angorn's [3] and 23.5% in the authors’ series). The previously referred funnel cuff tubes were proven to watertightly seal the space between the esophageal wall and flange (above the fistula) in all but four cases. In these instances a second stage reintubation achieved adequate tube position. Securing a patent noncommunicating central airway and near-normal oral intake are the two main requirements for a helpful palliation.
The most challenging condition is the combined malignant airway and esophageal tumor invasion with resulted strictures and fistula. In our series nine cases of Dumon stent (bronchial or tracheobronchial Y) implantation and a second stage esophageal tube insertion in two days time provided relief for our patients.
There is no doubt that the modern approach of the malignant tracheoesophageal fistula is a double stent placement [4]. However, the sad truth of this devastating complication is, that even the wide application of covered Ultraflex stents offers a limited ability to resume oral feeding (40% in Murthy et al. [5]).
An effective fistula palliation providing free oral intake and at the same time a lack of tracheobronchial complications seems to remain a challenging task.
References
This article has been cited by other articles:
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  A. Balazs, P. K. Kupcsulik, and Z. Galambos Reply to Kotsis Eur. J. Cardiothorac. Surg., July 1, 2009; 36(1): 226 - 226. [Full Text] [PDF]
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